THE GENERAL ASSEMBLY OF PENNSYLVANIA

HOUSE BILL

INTRODUCED BY D. COSTA, BARRAR, BRADFORD, BRENNAN, CALTAGIRONE, CASORIO, COHEN, CONKLIN, DEASY, DeLUCA, FREEMAN, GEORGE, GOODMAN, GRUCELA, HALUSKA, HARKINS, HENNESSEY, JOSEPHS, MAHONEY, MANN, MELIO, M. O'BRIEN, PASHINSKI, READSHAW, SIPTROTH, K. SMITH, SOLOBAY, J. TAYLOR, VULAKOVICH, WALKO, BELFANTI AND FRANKEL, APRIL 13, 2009

REFERRED TO COMMITTEE ON INSURANCE, APRIL 13, 2009  

AN ACT

Amending the act of May 17, 1921 (P.L.682, No.284), entitled "An

act relating to insurance; amending, revising, and

consolidating the law providing for the incorporation of

insurance companies, and the regulation, supervision, and

protection of home and foreign insurance companies, Lloyds

associations, reciprocal and inter-insurance exchanges, and

fire insurance rating bureaus, and the regulation and

supervision of insurance carried by such companies,

associations, and exchanges, including insurance carried by

the State Workmen's Insurance Fund; providing penalties; and

repealing existing laws," in long-term care, further

providing for definitions and for outline of coverage

provisions; providing for adverse decisions, for complaints,

for utilization review, for grievances and for prompt

processing and payment of claims; further providing for

authority to promulgate regulations; and providing for annual

report.

The General Assembly of the Commonwealth of Pennsylvania

hereby enacts as follows:

Section 1.  The definition of "long-term care insurance" in

section 1103 of the act of May 17, 1921 (P.L.682, No.284), known

as The Insurance Company Law of 1921, amended July 17, 2007

(P.L.134, No.40) is amended and the section is amended by adding

definitions to read:

Section 1103.  Definitions.--As used in this article, the

following words and phrases shall have the meanings given to

them in this section:

"Adverse decision."  A determination by a long-term care

insurance policy issuer that results in denial of payment of

benefits. The term includes the failure to pay a clean claim

within forty-five (45) days of receipt of the clean claim.

* * *

"Clean claim."  A claim for payment for a health care service

which has no defect or impropriety. A defect or impropriety

shall include lack of required substantiating documentation or a

particular circumstance requiring special treatment which

prevents timely payment from being made on the claim. The term

shall not include a claim from a health care provider who is

under investigation for fraud or abuse regarding that claim.

* * *

"Complaint."  A dispute or objection regarding the coverage,

operations or management policies of a long-term care insurance

issuer, which has not been resolved by the long-term care

insurance issuer and has been filed with the long-term care

issuer or with the Department of Health or the Insurance

Department. The term does not include a grievance.

"Concurrent utilization review."  A review by a utilization

review entity of all reasonably necessary supporting

information, which occurs during a policyholder or certificate

holder's course of treatment and results in a decision to

approve or deny payment for the health care service.

* * *

"Grievance."  A request by a policyholder, certificate holder

or health care provider, with the written consent of the

policyholder or certificate holder, to have a long-term care

insurance issuer or utilization review entity reconsider a

decision solely concerning the medical necessity and

appropriateness of a health care service. If the long-term care

insurance issuer is unable to resolve the matter, a grievance

may be filed regarding the decision that:

(1)  disapproves full or partial payment for a requested

health care service;

(2)  approves the provision of a requested health care

service for a lesser scope or duration than requested; or

(3)  disapproves payment for the provision of a requested

health care service but approves payment for the provision of an

alternative health care service. The term does not include a

complaint.

* * *

"Health care provider."  A licensed hospital or health care

facility, medical equipment supplier or person who is licensed,

certified or otherwise regulated to provide health care services

under the laws of this Commonwealth, including a physician,

podiatrist, optometrist, psychologist, physical therapist,

certified nurse practitioner, registered nurse, nurse midwife,

physician's assistant, chiropractor, dentist, pharmacist or an

individual accredited or certified to provide behavioral health

services.

"Health care service."  Any covered treatment, admission,

procedure, medical supplies and equipment or other services,

including behavioral health, prescribed or otherwise provided or

proposed to be provided by a health care provider to a

policyholder or certificate holder under a long-term care

insurance contract.

"Long-term care insurance."  Any insurance policy or rider

advertised, marketed, offered or designed to provide

[comprehensive] coverage for each covered person on an expense-

incurred, indemnity, prepaid or other basis for functionally

necessary or medically necessary diagnostic, preventive,

therapeutic, rehabilitative, maintenance or personal care

services provided in a setting other than an acute care unit of

a hospital. The term includes a policy, rider or prepaid home

health or personal care service policy [which provides for

payment of benefits based upon cognitive impairment or the loss

of functional capacity]. The term includes group and individual

policies or riders issued by insurers, fraternal benefit

societies, nonprofit health, hospital and medical service

corporations, health maintenance organizations or similar

organizations. The term does not include any insurance policy

which is offered primarily to provide basic Medicare supplement

coverage, basic hospital expense coverage, basic medical-

surgical expense coverage, hospital confinement indemnity

coverage, major medical expense coverage, disability income

protection coverage, accident-only coverage, specified disease

or specified accident coverage or limited benefit health

coverage. 

* * *

"Prospective utilization review."  A review by a utilization

review entity of all reasonably necessary supporting information

that occurs prior to the delivery or provision of a health care

service and results in a decision to approve or deny payment for

the health care service.

"Retrospective utilization review."  A review by a

utilization review entity of all reasonably necessary supporting

information which occurs following delivery or provision of a

health care service and results in a decision to approve or deny

payment for the health care service.

"Utilization review."  A system of prospective, concurrent or

retrospective utilization review performed by a utilization

review entity of the medical necessity and appropriateness of

health care services prescribed, provided or proposed to be

provided to a policyholder or certificate holder. The term does

not include any of the following:

(1)  Requests for clarification of coverage, eligibility or

health care service verification.

(2)  A health care provider's internal quality assurance or

utilization review process unless the review results in denial

of payment for a health care service.

"Utilization review entity."  Any entity certified pursuant

to section 1111.3 that performs utilization review on behalf of

a long-term care insurance issuer.

Section 2.  Section 1111 of the act, added December 15, 1992

(P.L.1129, No.148), is amended to read:

Section 1111.  Outline of Coverage Provisions.--(a)  An

outline of coverage shall be delivered to a prospective

applicant for long-term care insurance at the time of initial

solicitation through means which prominently direct the

attention of the recipient to the document and its purpose.

(b)  The department shall prescribe a standard format,

including style, arrangement and overall appearance, and the

content of an outline of coverage.

(c)  In the case of agent solicitations, an agent must

deliver the outline of coverage prior to the presentation of an

application or enrollment form.

(d)  In the case of direct response solicitations, the

outline of coverage must be presented in conjunction with any

application or enrollment form.

(e)  The outline of coverage shall include all of the

following:

(1)  A description of the benefits and coverage provided in

the policy.

(2)  A statement of the exclusions, reductions and

limitations contained in the policy.

(3)  A statement of the terms under which the policy or

certificate may be continued in force or discontinued, including

any reservation in the policy of a right to change premium.

Continuation or conversion provisions of group coverage shall be

specifically described.

(4)  A statement that the outline of coverage is a summary

only, not a contract of insurance, and that the policy or group

master policy contains governing contractual provisions.

(5)  A description of the terms under which the policy or

certificate may be returned and premium refunded.

(6)  A brief description of the relationship of cost of care

and benefits.

(7)  A summary of the long-term care insurance policy's

utilization review policies and procedures.

(8)  A summary of all complaint and grievance procedures used

to resolve disputes between the long-term care insurance policy

issuer and a policyholder, certificate holder or a health care

provider, including:

(i)  The procedure to file a complaint or grievance as set

forth in this article, including a toll-free telephone number to

obtain information regarding the filing and status of a

complaint or grievance.

(ii)  The right to appeal a decision relating to a complaint

or grievance.

(iii)  The right of a policyholder or certificate holder to

designate a representative to participate in the complaint or

grievance process as set forth in this article.

(iv)  A notice that all disputes involving denial of payment

for benefits will be decided by qualified personnel with

experience in the same or similar scope of practice and that all

notices of decisions will include information regarding the

basis for the determination.

(f)  An additional copy of the outline of coverage required

by subsection (a) shall be provided to consumers:

(i)  at least once every five (5) years beginning upon the

policyholder's or certificate holder's sixtieth birthday;

(ii)  upon receipt by the long-term care issuer of the first

claim for benefits under the policy filed by the policyholder or

certificate holder.

Section 3.  The act is amended by adding sections to read:

Section 1111.1.  Adverse Decisions.--When a long-term care

insurance issuer renders an adverse decision, the issuer shall

send, within five (5) working days after the adverse decision

has been made, a written notice to the policyholder or

certificate holder that states:

(1)  The specific factual basis, in clear, understandable

language for the issuer's decision.

(2)  The specific criteria and standards on which the

decision was based.

(3)  The policyholder's or certificate holder's right to

appeal the adverse decision.

(4)  The right of a policyholder or certificate holder to

designate a representative to participate in the complaint or

grievance process as set forth in this article.

(5)  The procedure to file a complaint or grievance, as

applicable.

(6)  The issuer's toll-free telephone number to obtain

information regarding the filing and status of a complaint or

grievance.

Section 1111.2  Complaints.--(a)  (1)  An issuer of a long-

term care insurance policy shall establish and maintain an

internal complaint process with two levels of review by which a

policyholder or certificate holder shall be able to file a

complaint regarding a participating health care provider or the

coverage, operations or management policies of the long-term

care insurance policy issuer.

(2)  The complaint process shall consist of an initial review

to include all of the following:

(i)  A review by an initial review committee consisting of

one or more employes of the long-term care insurance policy

issuer.

(ii)  The allowance of a written or oral complaint.

(iii)  The allowance of written data or other information.

(iv)  A review or investigation of the complaint which shall

be completed within thirty (30) days of receipt of the

complaint.

(v)  A written notification to the policyholder or

certificate holder regarding the decision of the initial review

committee within five (5) business days of the decision. Notice

shall include the basis for the decision and the procedure to

file a request for a second level review of the decision of the

initial review committee.

(3)  The complaint process shall include a second level

review that includes all of the following:

(i)  A review of the decision of the initial review committee

by a second level review committee consisting of three or more

individuals who did not participate in the initial review. At

least one-third of the second level review committee shall not

be employed by the long-term care insurance policy issuer.

(ii)  A written notification to the policyholder or

certificate holder of the right to appear before the second

level review committee.

(iii)  A requirement that the second level review be

completed within thirty (30) days of receipt of a request for

such review.

(iv)  A written notification to the policyholder or

certificate holder regarding the decision of the second level

review committee within five (5) business days of the decision.

The notice shall include the basis for the decision and the

procedure for appealing the decision to the department or the

Department of Health.

(b)  (1)  A policyholder or certificate holder shall have

fifteen (15) days from receipt of the notice of the decision

from the second level review committee to appeal the decision to

the department or the Department of Health, as appropriate.

(2)  All records from the initial review and second level

review shall be transmitted to the appropriate department in the

manner prescribed. The policyholder, certificate holder, the

health care provider or the long-term care insurance policy

issuer may submit additional materials related to the complaint.

(3)  The appropriate department shall determine whether a

violation of this article has occurred and may impose any

penalties authorized by this article.

(c)  Nothing in this article shall prevent the department or

the Department of Health from communicating with the

policyholder, certificate holder, the health care provider or

the long-term care insurance policy issuer as appropriate to

assist in the resolution of a complaint. Such communication may

occur at any time during the complaint process.

(d)  At any time throughout the complaint process in any

forum, the policyholder or certificate holder may be assisted or

represented by an attorney, Department of Aging long-term care

insurance ombudsman or representative, or other individual.

Section 1111.3  Utilization Review.--(a)  (1)  A utilization

review entity may not review health care services delivered or

proposed to be delivered in this Commonwealth pursuant to a

long-term care insurance policy unless the entity is certified

by the Department of Health to perform utilization review. A

utilization review entity operating in this Commonwealth on or

before the effective date of this section shall have one (1)

year from the effective date of this section to apply for

certification.

(2)  The Department of Health shall grant certification to a

utilization review entity that meets the requirements of this

section. Certification shall be renewed every three (3) years

unless otherwise subject to additional review, suspension or

revocation by the department.

(3)  The Department of Health may adopt a nationally

recognized accrediting body's standards to certify utilization

review entities to the extent the standards meet or exceed the

standards set forth in this article.

(4)  The Department of Health may prescribe application and

renewal fees for certification. The fees shall reflect the

administrative costs of certification and shall be deposited in

the General Fund.

(b)  (1)  A utilization review entity shall do all of the

following:

(i)  Respond to inquiries relating to utilization review

determinations by:

(A)  providing toll-free telephone access at least forty (40)

hours per week during normal business hours;

(B)  maintaining a telephone answering service or recording

system during nonbusiness hours; and

(C)  responding to each telephone call received by the

answering service or recording system regarding a utilization

review determination within one (1) business day of the receipt

of the call.

(ii)  Protect the confidentiality of the medical records of a

policyholder or certificate holder in compliance with all

applicable Federal and State laws and regulations and

professional ethical standards.

(iii)  Ensure that a health care provider is able to verify

that an individual requesting information on behalf of the long-

term care insurance policy issuer is a legitimate representative

of the long-term care insurance policy issuer.

(iv)  Conduct utilization reviews based on the medical

necessity and appropriateness of the health care service being

reviewed and provide notification within the following time

frames:

(A)  A prospective utilization review decision shall be

communicated within two (2) business days of the receipt of all

supporting information reasonably necessary to complete the

review.

(B)  A concurrent utilization review decision shall be

communicated within one (1) business day of the receipt of all

supporting information reasonably necessary to complete the

review.

(C)  A retrospective utilization review decision shall be

communicated within thirty (30) days of the receipt of all

supporting information reasonably necessary to complete the

review.

(v)  Ensure that personnel conducting a utilization review

have current licenses in good standing or other required

credentials, without restrictions, from the appropriate agency.

(vi)  Provide all decisions in writing to include the basis

and clinical rationale for the decision.

(vii)  Notify the health care provider of additional facts or

documents required to complete the utilization review within

forty-eight (48) hours of receipt of the request for review.

(viii)  Maintain a written record of utilization review

decisions adverse to policyholders or certificate holders for

not less than three (3) years, including a detailed

justification and all required notifications to the health care

provider and the policyholder or certificate holder.

(2)  Compensation to any person or entity performing

utilization review may not contain incentives, direct or

indirect, for the person or entity to approve or deny payment

for the delivery of any health care service.

(3)  Utilization review that results in a denial of payment

for a health care service shall be made by a licensed physician,

except as provided in clause (4).

(4)  A licensed psychologist may perform a utilization review

for behavioral health care services within the psychologist's

scope of practice if the psychologist's clinical experience

provides sufficient experience to review that specific

behavioral health care service. The use of a licensed

psychologist to perform a utilization review of a behavioral

health care service shall be approved by the Department of

Health as part of the certification process under section 2151.

A licensed psychologist shall not review the denial of payment

for a health care service involving inpatient care or a

prescription drug.

Section 1111.4  Grievances.--(a)  (1)  An issuer of a long-

term care insurance policy shall establish and maintain an

internal grievance process with two levels of review and an

expedited internal grievance process by which a policyholder,

certificate holder or a health care provider, with the written

consent of the policyholder or certificate holder, shall be able

to file a written grievance regarding the denial of payment for

a health care service. A policyholder or certificate holder who

consents to the filing of a grievance by a health care provider

under this section may not file a separate grievance.

(2)  The internal grievance process shall consist of an

initial review that includes all of the following:

(i)  A review by one or more persons selected by the long-

term care insurance policy issuer who did not previously

participate in the decision to deny payment for the health care

service.

(ii)  The completion of the review within thirty (30) days of

receipt of the grievance.

(iii)  A written notification to the policyholder or

certificate holder and health care provider regarding the

decision within five (5) business days of the decision. The

notice shall include the basis and clinical rationale for the

decision and the procedure to file a request for a second level

review of the decision.

(3)  The grievance process shall include a second level

review that includes all of the following:

(i)  A review of the decision issued pursuant to clause (2)

by a second level review committee consisting of three or more

persons who did not previously participate in any decision to

deny payment for the health care service.

(ii)  A written notification to the policyholder or

certificate holder or the health care provider of the right to

appear before the second level review committee.

(iii)  The completion of the second level review within

thirty (30) days of receipt of a request for such review.

(iv)  A written notification to the policyholder or

certificate holder and health care provider regarding the

decision of the second level review committee within five (5)

business days of the decision. The notice shall include the

basis and clinical rationale for the decision and the procedure

for appealing the decision.

(4)  Any initial review or second level review conducted

under this section shall include a licensed physician, or, where

appropriate, an approved licensed psychologist, in the same or

similar specialty that typically manages or consults on the

health care service.

(5)  Should the policyholder's or certificate holder's life,

health or ability to regain maximum function be in jeopardy, an

expedited internal grievance process shall be available, which

shall include a requirement that a decision with appropriate

notification to the policyholder or certificate holder and

health care provider be made within forty-eight (48) hours of

the filing of the expedited grievance.

(b)  (1)  An issuer of a long-term care insurance policy

shall establish and maintain an external grievance process by

which a policyholder, certificate holder or a health care

provider with the written consent of the policyholder or

certificate holder may appeal the denial of a grievance

following completion of the internal grievance process. The

external grievance process shall be conducted by an independent

utilization review entity not directly affiliated with the long-

term care insurance policy issuer.

(2)  To conduct external grievances filed under this section:

(i)  The Department of Health shall randomly assign a

utilization review entity on a rotational basis from the list

maintained under clause (4) and notify the assigned utilization

review entity and the long-term care insurance policy issuer

within two (2) business days of receiving the request. If the

Department of Health fails to select a utilization review entity

under this subsection, the long-term care insurance policy

issuer shall designate and notify a certified utilization review

entity to conduct the external grievance.

(ii)  The long-term care insurance policy issuer shall notify

the policyholder, certificate holder or health care provider of

the name, address and telephone number of the utilization review

entity assigned under this clause within two (2) business days.

(3)  The external grievance process shall meet all the

following requirements:

(i)  Any external grievance shall be filed with the long-term

care insurance policy issuer within fifteen (15) days of receipt

of a notice of denial resulting from the internal grievance

process. The filing of the external grievance shall include any

material justification and all reasonably necessary supporting

information. Within five (5) business days of the filing of an

external grievance, the long-term care insurance policy issuer

shall notify the policyholder, certificate holder or the health

care provider, the utilization review entity that conducted the

internal grievance and the Department of Health that an external

grievance has been filed.

(ii)  The utilization review entity that conducted the

internal grievance shall forward copies of all written

documentation regarding the denial, including the decision, all

reasonably necessary supporting information, a summary of

applicable issues and the basis and clinical rationale for the

decision to the utilization review entity conducting the

external grievance within fifteen (15) days of receipt of notice

that the external grievance was filed. Any additional written

information may be submitted by the policyholder, certificate

holder or the health care provider within fifteen (15) days of

receipt of notice that the external grievance was filed.

(iii)  The utilization review entity conducting the external

grievance shall review all information considered in reaching

any prior decisions to deny payment for the health care service

and any other written submission by the policyholder,

certificate holder or the health care provider.

(iv)  An external grievance decision shall be made by:

(A)  one or more licensed physicians or approved licensed

psychologists in active clinical practice or in the same or

similar specialty that typically manages or recommends treatment

for the health care service being reviewed; or

(B)  one or more physicians currently certified by a board

approved by the American Board of Medical Specialists or the

American Board of Osteopathic Specialties in the same or similar

specialty that typically manages or recommends treatment for the

health care service being reviewed.

(v)  Within sixty (60) days of the filing of the external

grievance, the utilization review entity conducting the external

grievance shall issue a written decision to the long-term care

insurance issuer, policyholder, certificate holder and the

health care provider, including the basis and clinical rationale

for the decision. The standard of review shall be whether the

health care service denied by the internal grievance process was

medically necessary and appropriate. The external grievance

decision shall be subject to appeal to a court of competent

jurisdiction within sixty (60) days of receipt of notice of the

external grievance decision. There shall be a rebuttable

presumption in favor of the decision of the utilization review

entity conducting the external grievance.

(vi)  The long-term care insurance policy issuer shall

authorize any health care service or pay a claim determined to

be medically necessary and appropriate under subclause (v)

pursuant to section 2166 whether or not an appeal to a court of

competent jurisdiction has been filed.

(vii)  All fees and costs related to an external grievance

shall be paid by the nonprevailing party if the external

grievance was filed by the health care provider. The health care

provider and the utilization review entity or long-term care

insurance policy issuer shall each place in escrow an amount

equal to one-half of the estimated costs of the external

grievance process. If the external grievance was filed by the

policyholder or certificate holder, all fees and costs related

thereto shall be paid by the long-term care insurance policy

issuer. For purposes of this clause, fees and costs shall not

include attorney fees.

(4)  The Department of Health shall compile and maintain a

list of certified utilization review entities that meet the

requirements of this article. The Department of Health may

remove a utilization review entity from the list if such an

entity is incapable of performing its responsibilities in a

reasonable manner, charges excessive fees or violates this

article.

(5)  A fee may be imposed by a long-term care insurance

policy issuer for filing an external grievance pursuant to this

article which shall not exceed twenty-five ($25) dollars.

(c)  Records regarding grievances filed under this article

that result in decisions adverse to policyholders or certificate

holders shall be maintained by the long-term care insurance

issuer for not less than three (3) years. These records shall be

provided to the Department of Health, if requested for purposes

of quality assurance, investigation of complaints or grievances,

enforcement or other activities related to compliance with this

article and other laws of this Commonwealth. Records shall be

accessible only to Department of Health employes or agents with

direct responsibilities under the provision of this subsection.

(d)  At any time throughout the grievance process in any

forum, the policyholder or certificate holder may be assisted or

represented by an attorney, Department of Aging long-term care

insurance ombudsman or representative, or other individual.

Section 1111.5  Prompt Processing and Payment of Claims.--(a)

Upon receipt of a claim for benefits, an insurer shall determine

whether it is complete. If it is not complete, within ten (10)

days of receipt thereof the insurer shall postmark to the

submitting person a statement of all items reasonably necessary

to be submitted to make the claim complete. Upon receipt of

those requested remaining items, the claim shall be complete and

all clean and uncontested portions thereof shall be paid within

thirty (30) days.

(b)  A long-term care insurance issuer shall pay a clean

claim submitted by a health care provider within forty-five (45)

days of receipt of the clean claim.

(c)  If a long-term care insurance issuer fails to remit the

payment as provided under subsection (a), interest at ten per

centum (10%) per annum shall be added to the amount owed on the

clean claim. Interest shall be calculated beginning the day

after the required payment date and ending on the date the claim

is paid. The long-term care insurance issuer shall not be

required to pay any interest calculated to be less than two ($2)

dollars.

(d)  (1)  In order to facilitate the prompt processing of

claims, each claim form processed or otherwise used by a long-

term care insurance issuer shall be the uniform claim form

developed by the department. Each form shall be identical,

except that the uniform claim form shall contain blank spaces at

appropriate places in the document for approved additional

information requests under clause (3).

(2)  The department shall forward the uniform claim form to

the Legislative Reference Bureau for publication as a notice in

the Pennsylvania Bulletin. A long-term care insurance issuer

shall be required to begin using the standard form as soon as

practicable following the publication but in no event later than

one hundred twenty (120) days following the publication.

(3)  A long-term care insurance issuer may request

departmental approval of additional information requests to be

printed in blank spaces on the uniform claim form, and on

subsequent pages if necessary, by submitting a written request

to the department. Such a request shall be deemed approved by

the department if not disapproved within sixty (60) days after

receipt of the request. A disapproval shall be subject to the

procedures under 2 Pa.C.S. (relating to administrative law and

procedure).

Section 4.  Section 1112 of the act, amended July 17, 2007

(P.L.134, No.40), is amended to read:

Section 1112.  Authority to Promulgate Regulations.--(a)  The

department shall promulgate reasonable regulations to establish

minimum standards for marketing practices, producer compensation

arrangements, producer testing, penalties and reporting

practices for long-term care insurance.

(b)  The department and the Department of Health may

promulgate reasonable regulations as may be necessary to carry

out the provisions of sections 1111.1, 1111.2, 1111.3 and

1111.4.

Section 5.  The act is amended by adding a section to read:

Section 1114.1  Annual Report.--Each long-term care insurance

issuer shall report annually to the commissioner on the form the

commissioner requires, a report that includes, but is not

limited to, the following information:

(1)  Information relating to adverse decisions, including:

(i)  The number of adverse decisions issued by the long-term

care insurance issuer under section 1111.1.

(ii)  The type of service at issue in the adverse decisions.

(2)  Information relating to complaints, including:

(i)  The number of complaints filed with the long-term care

insurance issuer.

(ii)  For each complaint filed with the long-term care

insurance issuer:

(A)  The outcome of the complaint.

(B)  Whether the complaint was resolved pursuant to the first

level internal review, second level internal review or before

the department or Department of Health.

(C)  The time within which the long-term care insurance

issuer resolved each complaint.

(3)  Information relating to grievances, including:

(i)  The number of grievances filed with the long-term care

insurance issuer.

(ii)  For each grievance filed with the long-term care

insurance issuer:

(A)  The outcome of the grievance.

(B)  Whether the grievance was resolved pursuant to the first

level internal review, second level internal review or external

grievance process.

(C)  Whether the grievance was subject to an expedited

review.

(D)  The time in which the long-term care insurance issuer

resolved each grievance.

(4)  Information relating to prompt payment of claims,

including:

(i)  The number of clean claims submitted by health care

providers not paid within forty-five (45) days of receipt of the

clean claim.

(ii)  The total amount of interest paid on claims not paid

within forty-five (45) days of receipt of the clean claim.

Section 6.  This act shall take effect in 60 days.